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>> Monday, June 8, 2009

Quadmama asked: Occasionally when I take my daughters to day care there is a sign posted saying some of the children have not been vaccinated. What risk does this pose to my children? Who is at a bigger risk in this situation: the unvaccinated kids or the vaccinated ones? I'm not trying to start a to-vaccinate-or-not debate, but I am curious about what all this means.

As I've mentioned before, I'm not a doctor and I knew, as big a topic as this is, that it needed an expert hand. I looked on Wikipedia on this, of course, but I didn't think it was good enough (though compelling in explaining why vaccinations are so damned important). I wanted an expert opinion damn it. Fortunately, I knew one. I contacted The Mother over on The Mother's Handbook and asked her to do a guest post for me. Fortunately for all of us, she complied. Without even calling me names.

She told me I could tone this down, but I'm not going to. I'll be frank. I look on those that think vaccinations haven't changed drastically (and for the better) the health of our children the same way I look at the Moon Hoax crowd. History is, in my opinion, unequivocal on this and, if you think simple childhood maladies can't kill, you don't know your history. My husband nearly died with chicken pox which manifested in his lungs. And he was born in 1983. I'm at a loss to understand parents who are willing to unnecessarily subject their children to disease. I'm not objective. To be honest, I don't know how you can know anything about science OR history and be so. Without more ado, here's The Mother.

Stephanie has asked me to field this question for her, being as she's a rocket scientist, and doesn't even play a doctor on TV. And I'm happy to do so, since I'm on record all over the blogosphere on this topic.

The answer to the first question is: it depends.

Herd immunity plays an enormous role in our protection from disease. Although vaccinated children should, theoretically, be protected from the diseases that they are vaccinated for, there are caveats.

The first is that some children don't mount the appropriate immune response to their vaccines. And we don't generally know which ones they are, because we do not routinely check titers for antibody response. It's not cost effective to do so, and as long as the children AROUND the non-responders are also vaccinated, herd immunity protects them from disease, just as if they, themselves, had developed antibodies.

The second is that some children are too young to develop an appropriate response to a particular vaccine. The vaccination schedule as currently recommended by the American Academy of Pediatrics is designed as it is largely because those dates are the very EARLIEST that a child can reasonably be expected to respond to that vaccine. If you have a little one who is too young to get, say, the MMR, and an unvaccinated child in the school contracts the measles, the youngster is at risk.

As to the second question: The unvaccinated children are, obviously, at great risk of developing dangerous, potentially lethal diseases that were on the brink of being eradicated just a decade ago, before all this anti-vax crap got started.

But yours MIGHT be just as at risk, for the reasons already mentioned.

Another risk: some vaccines "wear off." The biology behind this is fairly complicated, but the short version is that when a system isn't stimulated for a long time, the antibody-making cells just sort of disappear. We see this with tetanus, which is why we have always recommended a booster every ten years or so (tetanus comes from the soil, not from people, so it isn't part of the whole anti-vax risk scenario).

But the anti-vax movement has brought pertussis (whooping cough) back from oblivion. And our teens are starting to catch it, because their vaccines are wearing off. So current recommendations are that we send our teens back to the pediatrician for a TDaP (tetanus, diptheria, and acellular Pertussis).

The really, truly scary part of this wearing off phenomenon is that we honestly don't know what the wearing off risk is for immunity to some of the bugs that we thought were gone. Polio, for instance, is gone in America. But it's endemic in parts of Africa and India. Travelers to these areas are recommended to receive a polio booster.

In 1997, the US switched to using the IPV, a killed virus polio vaccine. This was done because polio had been essentially eradicated in the US. It is slightly less effective than the OPV, but carries fewer risks (the OPV is still the vaccination of choice in endemic areas, as it offers the best protection against all three wild strains).

Now imagine a traveler from India or Nigeria getting on a plane with an infective case of polio. If he or she runs into only vaccinated children, the virus won't have a chance to take hold in America. But if he manages to infect a few unvaccinated kids, we will have a new experiment on our hands. We will get to find out exactly what percentage of IPV receivers aren't immune to the wild virus. And we'll get to find out exactly what percentage of those vaccines wear off.

Terrifying, isn't it?

For an absolutely fabulous (and completely accurate) tutorial on the whole anti-vaccination movement, I refer you to Harriet Hall's impressive piece for eSkeptic magazine last week. She works through the entire hoax, from its beginnings in the laboratory of a doctor who received nearly $1million from plaintiff's attorneys, to the stupidity of Jenny McCarthy pitting her "mommy sense" against decades of scientific research.

And for a reminder of what the world used to be like, before vaccines, I refer you to David Oshinsky's excellent Polio: An American Story, about the scourge of polio, and the ordinary Americans who decided to fight back.

14
comments:

I knew medicine wasn't your area of expertise, but I knew you would come through. Thanks. Having preemies I never doubted I would vaccinate... their fragile immune systems needed protection. But even when I registered for the day care I take them to once a week there was a mom there waxing poetically about why she doesn't vaccinate her kids. Half the time the non-vaccine crowd makes me feel like a bad mother for vaccinating... well, to a degree, since they haven't changed my mind. The Mother raised a point I never even considered when she talks about vaccines "wearing out." I wondered why I had in recent years heard about teens catching whooping cough when we've been vaccinated for it.

I still don't understand the whole anti-vaccination movement. What are they thinking? Especially the whole "your kid can get autism from vaccinations." C'mon, the Wakefield study was shown to be deliberately biased and falsified 10 years ago, and these people still cite it! It boggles the mind.

Roy, I read the link The Mother provided (was just about to comment on it myself).

MIND BOGGLING!

What is wrong with people? Are you kidding me? Some of these disease are devastating and even the most benign can have dangerous, if not deadly complications. And you'd leave your children vulnerable? On nothing but paranoia and fear.

That Wakefield snake oil salesman (who should be held criminally responsible for many of these afflicted children) was discredited in Great Britain. Where is he now? Working in an autism clinic in the US!!!

This is insane! Do you think killing children through deliberate misinformation (murder) and determined ignorance (negligent homicide) makes it less criminal? Well, I don't agree.

Don't apologize, Stephanie. I usually RANT. I was trying to hold it down, since this isn't my blog.

I personally think that the children of anti-vaxers should be forcibly vaccinated, and that the perpetrators of the worst of the anti-vax movement (read, Jenny McCarthy, and maybe OPRAH, just for being stupid enough to give Jenny her own show) should be prosecuted for biological terrorism.

I was watching a show on mistakes parents make, and they interviewed several doctors, and all said the WORST mistake parents made was choosing not to immunize their kids.

The problem is that parents associate autism and other developmental conditions with immunizations because they notice alterations in their kids at about the same time the vaccinations occur. But we have absolutely NO evidence that such a link exists. Honestly, when my daughter was little, there was an outbreak of whooping cough in SC, where we lived, and nearly a dozen little kids died of it that winter. Where I live now, though, in WA, many parents opt for the no-immunization choice, since the state allows it. The minute something starts at the schools, though, their kids are sent home. Happened three times this year with chicken pox alone.

I'm still a bit worried about myself and smallpox. What if it comes up again? My husband was immunized... I was not, and my kids haven't been either.

The Mother will probably have a more pertinent answer, but I have to say that I think that's one of the most frustrating issues with this for doctors. Diseases we have all but eliminated could creep back and find a population now unprepared. Our kids don't get polio vaccines any more either (or they get only the oral but less effective one). That's a pretty scary thought.

For many of us, we have no real appreciation the scourges that were part of the culture for the generations that came before us: polio, smallpox, diptheria, whooping cough... We have no appreciation for the devastation those diseases did to families, to children, to the culture back then because we've beaten them.

Now, a little misinformation threatens to undo all that's been accomplished.

The lucky thing about smallpox is that it HAS been eradicated. The only smallpox in existence lives in very carefully controlled vials in laboratories.

That's why we stopped vaccinating for it.

The only way smallpox could possibly come back is bioterrorism. And more than a few thrillers have been written on that concept.

[Don't panic. There's almost no way it could happen. And the only reason we keep the vials in the labs is so we can mass produce vaccines if there ever IS a threat.]

We still DO vaccinate for polio; we just switched, in non-endemic areas, to the less dangerous IPV.

It's not really a risk, as long as herd immunity is working. The risk comes in if the herd immunity level drops due to non-vaccinators (I read a piece today that speculated that we need 90% vaccination rates to maintain herd immunity. If the folks I run into in the blogosphere are any indication, we're running really close).

Of course, herd immunity is the only thing protecting the non-vaccinators, too. These are the so-called "free-riders"--folks who don't pay their money or take the risks, but benefit from those who do. The fact that these free-riders are ALSO putting others at risk is just more ethical baggage piled on top.

For an interesting ethics lesson on the subject of free-riders, I refer you to Dr. Stemwedel at Adventures in Ethics and Science (http://scienceblogs.com/ethicsandscience/2009/06/vaccine_refuseniks_are_free-ri.php).

As for the "association" between autism and vaccines, it's a classic logical fallacy known as "post hoc, ergo prompter hoc"-- it happens after, therefore caused by.

The MMR is given at ABOUT the same time that the signs of autism begin. That was what the trial lawyers who paid Wakefield to fabricate his data were going for.

But the fallacy breaks down in evaluation. The rooster crows, and then the sun comes up. If we kill the rooster, does the sun not come out in the morning?

This is the language of magical thinking. It's the reason that virgins got thrown into volcanoes and people sacrificed portions of their crops to make sure that the Nile flooded every year.

I would hope that we've gotten past that. But, judging from the rhetoric of the anti-vaxers, as they vilify "Big Pharma" and accuse every real doctor out there of being "shills" for the pharmaceutical industry, I really doubt it. They're looking for a devil and a sacrificial lamb, and, by the gods, they're going to find it. It's so much easier than to deal with the fact that your child is autistic because of his GENES.

We scientist types are often accused of having science as our "religion."

And it's probably close to true. Because before I sacrifice my child to the volcano god, I'm gonna want to see some double-blinded, randomized, controlled trials.

And before any mother decides to sacrifice her child's health, and perhaps life, on the altar of the anti-vax community, she'd better have some solid data on her side.

But there isn't any. It's just as much abuse as if they were tossing them in the volcano.

Have any of you even researched the countless amount of doctors that have conducted their own research and refused to vaccinate their own kids? Do your own research and stop looking at the drug companies and your pediatrician as the know all. How many doctors have been wrong before? How many people has "researched and proven" drugs killed? I encourage everyone on this thread to take a look at both sides and make an educated guess. It is impossible to have a genetic epedemic!!! Autism is 1 and 140! Something changed and very recently.

Yes, anonymous, I have done my research and looked at the FACTS. The profit margin on vaccinations (in general) is so low that to argue the point is a waste for drug companies (who really haven't been part of the discussion that I've seen). And I haven't asked my pediatrician nor would I continue to go to one that argued against vaccinations. I would know (since I HAVE done my own research) that such a doctor would be a quack.

Why don't YOU look to the "experts" in the anti-vax side and see how many are getting huge sums from legal teams hoping to sue the pants off of everyone they can think of? Most of the folks talking on the other side are doctors who have nothing to gain other than the need to not undo several decades of disease management, not seeing children unnecessarily hospitalized and, yes, dead.

My son is supposed to be part of that autistic spectrum and I know, for a fact, that vaccines had nothing to do with it.

Genetics may not be the answer, but people have performed scientific studies that demonstrate conclusively that vaccines AREN'T the answer. Your volume and misinformation just cloud the issue and make it that much harder to find the real solution.

Obviously, anonymous, you didn't read Harriet Hall's article. She has done the research for you--ALL YOU HAVE TO DO IS READ.

As for the "countless doctors" who have decided not to immunize their own kids, I challenge you to find ANY that are not making big bucks from the autism community.

Doctors know how important vaccines are.

The fact is that the vaccine refuseniks have allowed us to conduct an experiment that no human subject review board would ever have allowed before--to compare the rates of autism in vaccinated and unvaccinated kids. Every study done has shown NO STATISTICALLY VALID DIFFERENCE (in fact, the rate of autism appears to be ever so slightly higher in the non-vaccinated groups, probably due to self-selection--people with autism in the family, for instance, may opt out of vaccines more commonly than those without).

As for the "genetic epidemic"-- we don't know why autism rates are rising. Some of it is clearly due to increased DIAGNOSIS. Children who a decade ago might have been simply labeled as "retarded" or "delayed" are clearly being put on the autism spectrum now.

BUT WE DO KNOW IT ISN'T VACCINES. Autism rates are NOT dropping as people opt out. They're increasing. And again, there is NO difference in the rates of autism in vaccinated and unvaccinated cohorts.

Anonymous, I strongly recommend that you start doing your own research, or at least start reading the REAL literature, rather than simply parroting the crap that the anti-vax community peddles. It isn't real. And your children will suffer, sooner or later.